Country Lane Gardens Rehab & Nursing Ctr

F 0565

Honor the resident's right to organize and participate in resident/family groups in the facility.

Level of Harm - Minimal harm or potential for actual harm

Based on review of Resident Council Meeting Minutes and staff interview, the facility failed to act promptly upon the grievances concerning issues of resident care voiced by residents at resident council meetings.

This affected nine (9) residents who attended the resident council meeting (Residents #7, #24, #49, #72, #74, #76, #80, #85, and #92). The facility census was 94.Findings include: Review of Resident Council Meeting Minutes from 08/13/25 revealed Residents #7, #24, #49, #72, #74, #76, #80, #85, and #92 attended the meeting. Concerns were voiced by unnamed residents regarding not receiving medications timely, staffing, and continuity of care. The page said to see back. However, there was nothing on the back of the form. There were no further specifics given as to what the resident concerns were regarding staffing and continuity of care. There was no evidence of any follow up by the facility to determine specifically what

the concerns were. There was no evidence of any action taken by the facility regarding the concerns.Evidence of what the specific concerns were and what action was taken by the facility was requested from the Administrator on 09/16/25 at 3:30 P.M., 09/17/25 at 3:00 P.M., and 09/18/25 at 7:45 A.M. with no response.This deficiency represents incidental findings of non-compliance investigated under Master Complaint Number 2623748.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

10/15/2025

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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

were referring the resident to the burn clinic.Review of the facility policy titled Change in a Resident's Condition or Status which was revised December 2016 revealed, unless otherwise instructed by the resident, a nurse will notify the resident's representative when: There is a significant change in the resident's physical status; It is necessary to transfer the resident to a hospital.Interview with Acting Director of Nursing #303 on 09/24/25 at 2:00 P.M. confirmed there was no evidence Resident #32's daughter was notified of the resident being outside in the sun and sustaining blisters on her arms and legs on 09/19/25 or

the fact that she was transferred to the hospital on [DATE REDACTED].This deficiency represents noncompliance investigated under Complaint Numbers 2623671, 2623597.

Event ID:

Facility ID:

If continuation sheet

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

10/15/2025

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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

outside. She stated she also told staff if she refused to come in, to get someone with good rapport with the resident. She stated there were days the resident was more irritable. The Administrator stated she was not at the facility on 09/19/25 when the incident happened. She stated that is why she felt SSA #150 was involved in the decision to allow the resident to go outside. Observations and interview with Nursing Assistant #217 on 09/29/25 at 9:13 A.M. revealed the keypad outside the exit door from the lounge by the Unit A, B, and C nurse's station does not work and will not allow anyone to come back inside the facility through that door once they are outside, unless someone inside opens the door for them. She stated it had been broken for months. She stated the maintenance man had tried to fix it but stated he needed to get ahold of the company. Interview with Acting Director of Nursing #303 on 09/29/25 at 9:13 A.M. confirmed

the keypad on the outside of the exit door did not work, even when the correct code was put in. She confirmed neither staff or residents (the residents were not provided the code) would be able to get back in if they went outside and the door closed. Interview with Maintenance Director #181 on 09/29/25 at 9:15 A.M. revealed the keypad outside of the exit door off the lounge by the Unit A, B, and C nurse's station had been broken for about two months. However, he stated he did not feel it was a priority at the moment. He stated staff could go in another door to get back into the facility. The nearest door in the courtyard was approximately 120 feet from the door with the broken keypad and required staff to go upstairs. (They would be unable to take a resident inside who was in a wheelchair or having a medical emergency). Review of the facility policy last revised [TRUNCATED]

Event ID:

Facility ID:

If continuation sheet

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

10/15/2025

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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

proof of delivery reports revealed the pharmacy delivered 30 tablets of Oxycodone 15 milligrams to the facility for Resident #51 on 07/10/25, 07/18/25, 07/27/25, 08/02/25, 08/09/25, and 08/15/25 for a total of 180 tablets. Review of medication administration records for Resident #51 from 07/10/25 to 08/23/25 revealed she was given 78 tablets of Oxycodone 15 milligrams. She should have had 102 tablets left on 08/23/25. On 08/23/25 30 more tablets were delivered from the pharmacy. The total should have been 132.

Review of the medication administration record for 08/24/25 to 08/29/25 revealed she was given seven tablets. Therefore, when LPN #195 noted on 08/29/25 that there was no Oxycodone available, she should have had 125 tablets left. In addition, review of the controlled medication shift change log revealed that on 08/28/25, RN #227 signed in one card and one sheet of Alprazolam for Resident #81. She documented that 45 pills were delivered. Review of the controlled substance administration records for Resident #81 revealed on 08/28/25, two sheets and two cards were delivered (one with 30 pills and one with 15 pills).

Both sheets and both cards were placed into the narcotic counts. By only signing in one sheet and one card, you would be able to take out a card and sheet belonging to someone else without the count being off. Interview with Regional Nurse #200 on 09/17/25 at 10:30 A.M. and 10:50 A.M. revealed the initial allegation was made on 09/03/25. She confirmed there were Oxycodone sent for Resident #51 that are not accounted for from the documentation. She confirmed the facility did not have a summary or conclusion of their investigation into the allegation of missing narcotics for Resident #51. She stated that since the allegation focused on RN #227, she was drug tested. (Test negative on 09/06/25). She confirmed the facility did not investigate the allegation regarding the Alprazolam being signed in inappropriately for Resident #81.

She confirmed that RN #227 only signed in one sheet and one card of Alprazolam for Resident #81 on 08/28/25. She confirmed it should have been two sheets and two cards. She confirmed that it was around that time when Resident #51's card of oxycodone was missing (08/29/25 per staff statements). She confirmed Resident #51 did not receive any Oxycodone from 08/28/25 to 08/31/25, when more were sent

on 08/31/25. She stated that education was done with nursing on the day she was aware of the allegation (09/03/25) after it was determined what a mess it was. She stated that the pharmacy was notified 09/03/25 but was not involved in doing any investigation into missing narcotics. She stated she was notified last night that Resident #51 stated she did not receive a pain pill. She stated that the unit manager had called RN #227 to verify that she gave the medication. She stated she was not aware that Resident #51 had stated that RN #227 was stealing her medications. Interview with LPN/Unit Manager #175 on 09/17/25 at 1:30 P.M. confirmed Resident #81 had two count sheets for Alprazolam on 08/28/25 when RN #227 only signed one into the count. She stated this would make the count wrong unless a card and sheet were removed by someone. RN #227 was observed working in the facility on B-Hall on 09/16/25 and 09/17/25 on day shift.

Review of the facility policy last revised 10/27/17 and titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed the facility will not tolerate abuse, neglect, exploitation of its residents or the misappropriation of resident property. Misappropriation of resident property was defined as

the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. This deficiency represents noncompliance investigated under Master Complaint Number 2623748, 2615387, 2608772, 2608729.

Event ID:

Facility ID:

If continuation sheet

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

10/15/2025

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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

symptoms and/or treatment related psychosis or mania (high dose steroids), Tourette's disorder, Huntingtons disease, Hiccups, nausea and vomiting associated with cancer or chemotherapy. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident and others and the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations, delusions, paranoia, or grandiosity); or behavioral interventions have been attempted and included in the plan of care. Interview with the Acting Director of Nursing #303 on 09/24/25 at 2:00 P.M. confirmed there was no reason documented for the use of the Haldol on 09/22/25 at 4:54 A.M. except that she had pulled the fire alarm earlier. She stated in order to give the Haldol, there would have had to be an imminent danger to self or others and there was no evidence of that. She confirmed the order had originally been obtained when the resident refused to get off

the stretcher on 09/21/25 when returning from the hospital.This deficiency represents incidental findings of non-compliance investigated under Master Complaint Number 2623748.

Event ID:

Facility ID:

If continuation sheet

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

10/15/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

tablets. Review of medication administration records for Resident #51 from 07/10/25 to 08/23/25 revealed

she was given 78 tablets of Oxycodone 15 milligrams. She should have had 102 tablets left on 08/23/25. On 08/23/25 30 more tablets were delivered from the pharmacy. The total should have been 132. Review of the medication administration record for 08/24/25 to 08/29/25 revealed she was given seven tablets. Therefore, when LPN #195 noted on 08/29/25 that there was no Oxycodone available, she should have had 125 tablets left. In addition, review of the controlled medication shift change log revealed that on 08/28/25, RN #227 signed in one card and one sheet of Alprazolam for Resident #81. She documented that 45 pills were delivered. Review of the controlled substance administration records for Resident #81 revealed on 08/28/25, two sheets and two cards were delivered (one with 30 pills and one with 15 pills). Both sheets and both cards were placed into the narcotic counts. By only signing in one sheet and one card, you would be able to take out a card and sheet belonging to someone else without the count being off. Interview with Regional Nurse #200 on 09/17/25 at 10:30 A.M. and 10:50 A.M. revealed the initial allegation was made on 09/03/25. She confirmed there were Oxycodone sent for Resident #51 that are not accounted for from the documentation. She confirmed the facility did not have a summary or conclusion of their investigation into

the allegation of missing narcotics for Resident #51. She stated that since the allegation focused on RN #227, she was drug tested. (Test negative on 09/06/25). She confirmed the facility did not investigate the allegation regarding the Alprazolam being signed in inappropriately for Resident #81. She confirmed that RN #227 only signed in one sheet and one card of Alprazolam for Resident #81 on 08/28/25. She confirmed it should have been two sheets and two cards. She confirmed that it was around that time when Resident #51's card of oxycodone was missing (08/29/25 per staff statements). She confirmed Resident #51 did not receive any Oxycodone from 08/28/25 to 08/31/25, when more were sent on 08/31/25. She stated that education was done with nursing on the day she was aware of the allegation (09/03/25) after it was determined what a mess it was. She stated that the pharmacy was notified 09/03/25 but was not involved in doing any investigation into missing narcotics. She stated she was notified last night that Resident #51 stated she did not receive a pain pill. She stated that the unit manager had called RN #227 to verify that she gave the medication. She stated she was not aware that Resident #51 had stated that RN #227 was stealing her medications. Interview with LPN/Unit Manager #175 on 09/17/25 at 1:30 P.M. confirmed Resident #81 had two count sheets for Alprazolam on 08/28/25 when RN #227 only signed one into the count. She stated this would make the count wrong unless a card and sheet were removed by someone. RN #227 was observed working in the facility on B-Hall on 09/16/25 and 09/17/25 on day shift.

Review of the facility policy last revised 10/27/17 and titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed the facility will not tolerate abuse, neglect, exploitation of its residents or the misappropriation of resident property. Misappropriation of resident property was defined as

the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The policy stated that the administrator or designee will notify the State Survey Agency of all alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property and injuries of unknown source as soon as possible but in no event later than 24 hours from the time the incident/allegation was make known to the staff member. There was no evidence the facility reported the allegation of missing narcotics to the State Survey Agency prior to 09/17/25. Interview with Regional Nurse #200 on 09/17/25 at 10:50 A.M. confirmed the facility did not report the allegation of missing narcotics to the State Survey Agency. This deficiency represents non-compliance investigated under Master Complaint Number 2623748, 2615387, 2608772,

1. 2608729. Event ID:

Facility ID:

If continuation sheet

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

10/15/2025

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

#14's mood was stable at this time. SSD and UM educated Resident #14 on not going into male resident rooms and to get staff if someone requested help. Resident #14 had no issues or concerns at this time. In addition, there was a general note dated 09/22/25 at 5:49 A.M. that stated Resident #14 remained on 1:1 supervision during that shift.

Review of the medical record for Resident #50 revealed an admission date of 12/05/24 with diagnoses that included spastic hemiplegia affecting the left side, dementia, seizures, hypothyroidism, hyperlipidemia, hypertension, ischemic cardiomyopathy, hyperplasia without lower urinary tract symptoms, adult failure to thrive, anxiety, mood disorder, major depressive disorder, contracture, and paraphilia.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] for Resident #50 revealed

a BIMS score of 05, indicating severe cognitive impairment. Physical and verbal behaviors occurred 1–3 days per week. Resident #50 had one-sided limb impairment, used a wheelchair, required supervision for eating, was dependent for all other daily activities, required maximal help for bed mobility and transfers, and could not walk more than 10 feet.

Review of the progress notes for Resident #50 revealed no mention of the sexual abuse that occurred between Resident #14 and himself.

Interview on 09/24/25 at 9:00 A.M. with Certified Nursing Assistant (CNA) #167 revealed that she observed Resident #14 standing next to Resident #50's bed touching him inappropriately. Resident #14 stated she was putting his shirt on while touching his penis. CNA #167 notified the nurses, wrote a report, and the Assistant Director of Nursing (ADON) and management were informed. She estimated the incident occurred Thursday or Friday around 10–11 A.M. but could not recall the exact date and time. She stated Resident #14 was placed on 1:1 supervision for a few hours, then on 15-minute checks. She was unaware of any other incidents between the residents and noted no preventive measures had been in place prior to the incident occurring. CNA #167 stated she did not know how long Resident #14 was in Resident #50's room and only witnessed the ending of what had occurred in the room.

Interview on 09/25/25 at 12:16 P.M. with CNA #204 revealed that the sexual abuse incident between Resident #14 and Resident #50 had already occurred prior to her shifts. She stated that she did not fill out

the 1:1 paperwork herself and that Scheduling Coordinator #150 had completed the initial documentation.

CNA #204 confirmed she completed her assigned 1:1 supervision on her shifts but did not personally document initials.

Interview on 09/25/25 at 12:23 P.M. with CNA #191 revealed that Scheduling Coordinator #150 had completed the 1:1 paperwork on his behalf. He reported that he did not personally complete all assigned 1:1s. He stated that on Friday night no 1:1s occurred and on Saturday night there was a two-hour gap from midnight to 2:00 A.M. during which no 1:1 supervision was provided. He indicated that day shift staff had no paperwork for him to begin documentation.

Review of the 1:1 initialed check sheet revealed that all initials were present, including during the reported gaps when no 1:1s occurred. The initials for both CNA #204 and CNA #191 were present, even though each confirmed they did not complete any 1:1 documentation during their shifts, resulting in gaps in protection for other residents on the locked unit.

This deficiency represents non-compliance investigated under Master Complaint Number 2623748, Complaint Numbers 2615387, 2608772, 2608729.

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

Event ID:

Facility ID:

If continuation sheet

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

10/15/2025

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 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

Based on record review, staff interview, and resident interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. This affected one (#51) of three residents reviewed for showers/bathing. The facility census was 94.Findings include:Review of the medical record for Resident #51 revealed an admission date of 06/23/25 and diagnoses including Bipolar disorder, diabetes, chronic kidney disease, and congestive heart failure. Review of the Minimum Data Set assessment completed 07/10/25 revealed a brief interview for mental status (BIMS) score of 13, indicating intact cognition. It further indicated the resident was always incontinent of bowel and bladder, was dependent for toileting, and required substantial/maximal assistance with bathing.Interview with Resident #51 on 09/16/25 at 1:05 P.M. revealed she normally only gets one shower per week and that is when she asks for it. She stated she would prefer two per week.Review of shower sheets for the past month revealed Resident #51 received showers on 08/01/25, 08/12/25, 08/19/25, 08/20/25, 09/05/25, and 09/10/25.Interview with Regional Nurse #200 on 09/22/25 at 9:20 A.M. revealed Resident #51 had not been placed on the shower schedule. Therefore, she was not being provided/offered showers twice weekly as she should be. She confirmed the resident had only received six showers since 08/01/25.This deficiency represents noncompliance investigated under Complaint Number

1. 2596564. Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

10/15/2025

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 - Immediate jeopardy to resident health or safety Residents Affected - Few

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

attempts were made to contact RN #237 after the interview with CNA #249 with voicemail messages left with each attempt. No return calls were provided. Interview on 09/23/25 at 4:20 P.M. with LPN #198 revealed she did not recall Resident #95 having dusky colored hands or feet on the evening of 06/27/25 when she was caring for the resident nor did she recall any other staff reporting this to her on this date.

LPN #198 stated she only worked every other weekend (please note, there was no documentation in the resident's medical record of the resident's status for the LPN to review for 06/27/25, 06/28/25 or 06/29/25 prior to the resident's transfer to the hospital).Interview on 09/23/25 at 4:25 P.M. with Medical Director #301 revealed the resident's overall condition would have been documented in his progress notes if he was notified of the resident's condition change. Further interview revealed it would be his expectation nursing would evaluate a resident experiencing a condition change and then notify him, the CNP or the on-call medical provider to obtain orders.Interview on 09/24/25 at 1:30 P.M. with Acting Director of Nursing #303 revealed Resident #95 should have been assessed, the medical provider contacted, and the resident transferred to the hospital or discussed hospice and end-of-life care when the change of condition was reported. The Acting DON verified a root cause analysis completed by the facility following the concern with Resident #95's care identified the cause was the facility's failure to assess the resident when the CNAs reported to different nurses she was exhibiting changes in condition with discolored hands and feet, wearing oxygen and not acting per her usual. The Acting DON verified the delay in assessment and notification of the resident's condition change resulted in the resident being transported to the hospital at which time the resident's condition was determined to be terminal and she was transferred to a hospice facility and then passed away. The Acting DON confirmed the facility did not identify the delay in treatment until the concern was identified by the State Survey Agency so an investigation into the incident involving Resident #95 was not previously initiated. The Acting DON verified her expectations of the nursing staff would have been to assess the resident when the changes were reported and notify the medical practitioner of the resident's needs, including the use of oxygen so additional treatment orders or interventions could have been implemented. Review of the policy titled Change in a Resident's Condition or Status revealed the facility is to promptly notify the resident, the resident's attending medical provider, and

the resident's representative of changes in the resident's medical/mental condition. Further review revealed nurse is to record information related to the resident's change in condition in the resident's medical record.Review of the facility assessment dated [DATE REDACTED] revealed that under the area of services and care offered the facility would manage medical conditions by assessment, early identification of problems or deterioration. Further review indicated that all newly hired personnel receive training during their orientation

on identification of resident changes in condition including how to identify medical issues appropriately and how to determine if symptoms represent problems in need of intervention.This deficiency represents non-compliance investigated under Complaint Number 2615387.

Event ID:

Facility ID:

If continuation sheet

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

10/15/2025

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 0687 Level of Harm - Actual harm Residents Affected - Few

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

surgeon on 07/02/25 (his first scheduled appointment after his vascular procedure), 09/08/25, and 09/10/25 (please note, the facility did not reschedule the cancelled 07/02/25 appointment until September with testing on 09/08/25 and a vascular surgeon appointment on 09/10/25; however, both September appointments were cancelled due to no transportation and the resident had not been seen by the vascular surgeon since his procedure was done on 05/23/25). Interview with CNP #202 on 09/22/25 at 11:39 A.M. revealed she was aware of the facility not being able to 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. Interview with Physician/Medical Director #301 on 09/22/25 at 1:45 P.M. revealed he was aware Resident #79 had the angiogram with an intervention to open and dilate the right leg artery on 05/23/25. He stated that going to a follow-up appointment would have checked to see if things were still ok.

Interview with Nurse Supervisor #700 at the vascular surgeon's office on 09/22/25 at 3:40 P.M. (to discuss

the procedure discharge instructions for 05/23/25) revealed Resident #79 had the angiogram done on 05/23/25 with physician orders upon discharge to begin Plavix 75 mg daily and continue Aspirin 81 mg daily. (Plavix is used with Aspirin following angioplasty with stenting to prevent the stent from closing).

Nurse Supervisor #700 stated the Aspirin 81 mg had been ordered by the vascular surgeon on 03/25/25.

Further interview revealed their office began calling the facility on 05/30/25 to schedule a follow-up visit with

the vascular surgeon but they had difficulty reaching the facility and had to call the facility five times to get someone to answer the phone. Finally, on 06/03/25 they were able to talk to someone and a follow-up visit was scheduled with the vascular surgeon for 07/02/25. However, the facility called on 07/02/25 and cancelled the appointment due to a lack of transportation. The nurse supervisor shared the facility did not call back to reschedule the appointment until September 2025. She stated testing was scheduled for 09/08/25 and a follow up visit on 09/10/25. However, those appointments were also cancelled on 09/05/25 due to the facility having no transportation. She confirmed the resident had not been seen by the vascular surgeon since 05/23/25. During the interview, the nurse supervisor revealed not receiving the Plavix medication could impair the stent that was put in and cause occlusion of blood flow. She stated impaired blood flow in the legs could cause worsening of the wounds and osteomyelitis. Lastly, the nurse supervisor indicated the purpose of follow-up appointments was to verify how the patient was progressing after their procedure, and the patient (Resident #79) should have been transported to the appointments to be evaluated by the physician and monitor healing. Interview with RN/Vice President of Clinical Operations #300 on 09/23/25 at 11:45 A.M. confirmed Resident #79 had not received Aspirin as ordered. She believed

it had been discontinued on 11/14/24. She also confirmed the resident had not received the Plavix that was ordered on 05/23/25. This deficiency represents noncompliance investigated under Complaint Number 2623671, 2623597, 2619174.

Event ID:

Facility ID:

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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

10/15/2025

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 0692 Level of Harm - Actual harm Residents Affected - Few

that staff were expected to record in the Medication Administration Record (MAR) the percentage of the supplement consumed, and if intake was low, staff should offer an alternative supplement to determine if

the resident preferred it. The RD confirmed that the recommended 120 ml house supplement for Resident #65 had not yet been initiated as of the interview date, despite being recommended in the progress notes.

She emphasized that timely implementation and monitoring of nutrition interventions were critical to addressing weight loss and preventing further nutritional decline.

Review of the facility policy titled, Weight Assessment and Intervention dated 01/13/23 revealed that a 5% or greater weight change since the last assessment triggered a re-measurement the next day, with the nurse notifying the Dietitian in writing for confirmation within 24 hours, who then responded within 24 hours to recommend trends over time. Significant weight loss was defined as 5% in one month (severe if >5%), 7.5% in three months (severe if >7.5%), or 10% in six months (severe if >10%), with desirable changes documented without care plan adjustments. The multidisciplinary team analyzed assessment data, considering target weight ranges, medical conditions, and potential causes such as anorexia or cognitive decline, and developed individualized care plans with goals, benchmarks, and monitoring timelines, ensuring resident preferences and rights were respected, including documentation if a resident declined intervention.

This deficiency represents non-compliance investigated under Complaint Number 2615387.

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

Event ID:

Facility ID:

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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

10/15/2025

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 0698 Level of Harm - Minimal harm or potential for actual harm

person at the facility whose responsibilities include assisting with the coordination of renal dialysis services for end stage renal disease residents. It further stated obligations of the dialysis center included to provide to the facility information on all aspects of the management of the resident's care related to the provision of renal dialysis services. This deficiency represents incidental finding of noncompliance investigated under Complaint Number 2623671.

Residents Affected - Few

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

Event ID:

Facility ID:

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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

10/15/2025

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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on review of facility staffing reports, review of facility staff time punches and staff interviews, the facility failed to provide eight hours of consecutive Registered Nurse (RN) direct care and had the Regional Director of Nursing as providing resident care for three days reviewed in a seven-day (one week) period.

This had the potential to affect all 94 residents living in the facility. Findings include:A review of the facility staffing reports dated 09/04/25, 09/05/25, and 09/10/25 revealed that the facility did not have a Registered Nurse scheduled for eight hours of consecutive direct care on those three dates. Regional Director of Nursing #200 was scheduled to be the Director of Nursing in the building for 09/04/25, 09/05/25, and 09/10/25. A review of the punch report dated 09/04/25 through 09/10/25 revealed that no RN coverage was

in place for 09/04/25, 09/05/25, and 09/10/25. An interview with Regional Director of Nursing #200 on 09/16/25 at 2:03 P.M. revealed that she was in the facility on 09/04/25, 09/05/25, and 09/10/25 providing resident care. An interview with Staffing Coordinator #150 on 09/16/25 at 3:31 P.M. confirmed that Regional Director of Nursing #200 was the only RN in the building on 09/04/25, 09/05/25, and 09/10/25, and that no other RNs had worked on 09/04/25, 09/05/25, and 09/10/25. An interview with the Administrator on 09/16/25 at 4:01 P.M. revealed that the facility did not have a policy on RN coverage requirements in the building; however, the Administrator confirmed that she knew that it was a regulation to have 8 hours of consecutive RN coverage, seven days a week and that the Director of Nursing could not serve as the RN coverage for the facility. This deficiency represents non-compliance investigated under Master Complaint Number 2623748, Complaint Number 2615387, 2596564.

Event ID:

Facility ID:

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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

10/15/2025

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 0740

Master Complaint Number 2623748.

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

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

Event ID:

Facility ID:

If continuation sheet

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

10/15/2025

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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

notified that the Epoetin alfa was not given as ordered. Interview with [NAME] President of Clinical Operations #300 on 09/23/25 at 11:45 A.M. confirmed Resident #40 was prescribed medications from the same drug class at the dialysis center and at the facility, with neither knowing that the other one was giving them. In addition, Resident #40 had a physician's order for Tramadol (an opioid pain medication) 50 milligrams every six hours as needed for pain on 07/19/25. Review of the controlled substance administration record revealed the resident received Tramadol 50 milligrams at 6:07 P.M. on 07/24/25.

Review of the medication administration record revealed the dose on 07/24/25 at 6:07 P.M. was not documented as given. Review of the medication administration record and the controlled substance administration record revealed he received another dose on 07/24/25 at 9:19 P.M. (three hours and 12 minutes after the previous dose). The medication should not have been given until six hours had passed.

Interview with [NAME] President of Clinical Operations #300 on 09/23/25 at 9:00 A.M. confirmed that Resident #40 received the dose of Tramadol too soon on 07/24/25. Review of the facility policy revised December 2012 and titled Administering Medications revealed medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. The individual administering the medication must initial the resident's medication administration record on the appropriate line after giving each medication and before administering the next one. This deficiency represents noncompliance investigated under Complaint Number 2623671, 2623597, 2615397.

Event ID:

Facility ID:

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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

10/15/2025

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 0835

all facility departments. This deficiency represents incidental findings of noncompliance investigated under Complaint Number 2623671.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Event ID:

Facility ID:

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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

10/15/2025

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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Director of Operations #350 and Regional Director of Clinical Services #201 on 09/29/25 at 1:40 P.M. revealed they were not aware prior of any of the issues identified by survey team including failure to provide transportation and ordered medication for Resident #79 resulting in osteomyelitis of the foot, misappropriation of narcotics for Resident #51, failure to identify a significant change in condition for Resident #95 resulting in severe dehydration and death, and significant medication errors for Residents #3 and #40. Review of the policy dated July 2016 and titled Quality Assurance and Performance Improvement (QAPI) Committee revealed the facility shall establish and maintain a QAPI Committee that oversees the implementation of the QAPI program. The committee shall be a standing committee of the facility and shall provide reports to the Administrator and governing body. Goals of the committee included establish, maintain, and oversee facility systems and processes to support the delivery of quality of care and services; Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately; Support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systemic problems; Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals. This deficiency represents incidental findings of noncompliance investigated under Complaint Number 2623671.

Event ID:

Facility ID:

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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

10/15/2025

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 0841 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

dialysis facility three times weekly for hemodialysis. Review of nursing progress notes revealed on 07/25/25 at 5:26 P.M. it was documented that the resident had a critically low hemoglobin of 6.9. (normal 14-18). (Hemoglobin is a protein in red blood cells that carries oxygen throughout the body). It was documented that the nurse practitioner was notified and a new order was given. A blood test completed on 07/25/25 verified the hemoglobin level of 6.9. Review of the medication administration record revealed Ferrous Sulfate 325 milligrams was increased from every other day to daily on 07/25/25.On 07/28/25 there was a written physicians order from Physician #301 for Epoetin alfa 10,000 units weekly for four weeks. (Epoetin alfa is used to treat anemia by stimulating the production of red blood cells. Review of medication administration records revealed the Epoetin alfa 10,000 units was not given as scheduled on 07/29/25, 08/05/25, or 08/19/25 due to not being available from the pharmacy. He did receive a dose on 08/12/25.

There was no evidence the physician was notified of the medication not being available from the pharmacy.

However, review of a dialysis anemia patient history graph revealed Resident #40 had received Mircera (a drug from the same drug class as Epoetin alfa) to treat low hemoglobin on 07/28/25, 08/11/25, 08/25/25, and 09/08/25. Interview with RN #701 from the dialysis center on 09/23/25 at 8:37 A.M. confirmed Mircera and Epoetin alfa were from the same drug class (one long acting and one short acting). She confirmed Resident #40 had received Mircera every two weeks since 07/28/25 at the dialysis center. She stated the dialysis center was not aware that he had an order to receive Epoetin alfa weekly at the facility. She stated if they would have known that, he would not have received the Mircera at the dialysis center. She confirmed there should be collaboration between the dialysis center and the facility regarding care provided and medications given. Interview with Physician #301 on 09/22/25 at 1:45 P.M. revealed he did not remember if

he was notified of Resident #40 not receiving the weekly Epoetin alfa as ordered. He stated he knew the resident was receiving dialysis but was not aware of medications being provided by the dialysis center. He stated that information was not available. Review of an undated policy titled Medical Director Review revealed the medical director, in a collaborative effort with the facility, will coordinate medical care and ensure implementation of resident care policies. The policy stated the medical director would attend and participate in the facility QA meeting on at least a quarterly basis. The medical director will provide input at QA meetings and other times as warranted regarding any perception of deficient clinical practices. The medical director will offer guidance and suggestions as to management of clinical problems. Review of the job description for Medical Director revealed the purpose of this position is to participate in development of resident care policies to provide total medical and psychosocial needs of residents, assist administration in implementing resident care policies, and participate in the facility quality assessment and assurance program. This deficiency represents incidental findings of noncompliance investigated under Complaint Number 2623671.

Event ID:

Facility ID:

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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

10/15/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on record review, observations, and staff interview, the facility failed to ensure resident records were complete and accurately documented. This affected four (#6, #40, #79, and #81) of 17 sampled residents.

The facility census was 94. Findings include:1.Review of the medical record for Resident #6 revealed an admission date of 01/18/18 and diagnoses including anxiety disorder, hypertension, and chronic obstructive pulmonary disease. The resident had a physician's order for Ativan (an antianxiety medication) one milligram three times daily at 9:00 A.M., 3:00 P.M., and 9:00 P.M. Review of the medication administration

record for September 2025 revealed the Ativan was documented as given on 09/07/25 at 9:00 A.M.

However, review of the controlled substance administration record revealed Ativan was not signed out as given on 09/07/25 at 9:00 A.M. Interview with LPN/Unit Manager #241 on 09/17/25 at 2:15 P.M. confirmed

the medication was documented as given on the medication administration record but had not been signed out on the controlled substance administration record on 09/07/25. She confirmed this was not accurate. 2.Review of the medical record for Resident #40 revealed an admission date of 07/10/25 with diagnoses including diabetes, end stage renal disease, and left leg below the knee amputation. The resident had a physician's order for Tramadol (an opioid pain medication) 50 milligrams every four hours as needed for pain. Review of Controlled substance administration records revealed the Tramadol was signed out as given

on 07/24/25 at 6:07 P.M., 08/06/25 at 10:35 P.M., 08/16/25 at 4:00 A.M., 08/17/25 at 10:20 P.M., 08/26/25 at 12:30 A.M., and 09/14/25 at 6:24 P.M. (three of the doses by LPN #223). Review of the medication administration records for July, August, and September 2025 revealed that those doses were not signed as given on the medication administration records. Interview with [NAME] President of Clinical Operations #300 on 09/23/25 at 9:00 A.M. confirmed the documentation for the doses of Tramadol given to Resident #40 did not match on the medication administration records and the controlled substance administration records and should have.3. Review of the medical record for Resident #79 revealed an admission date of 06/15/24 and diagnoses including peripheral vascular disease, dementia, and diabetes. Review of wound consult notes on 09/16/25 revealed he currently had multiple arterial wounds to both feet. Observations on 09/18/25 at 2:30 P.M. revealed Resident #79 to be in bed with Prevalon boots on both feet (used to float heels and reduce the risk of pressure wounds). Review of the medical record revealed the resident did not have a physician's order for the Prevalon boots and the boots were not listed as an intervention on the plan of care.Interview with Acting Director of Nursing #303 on 09/24/25 at 10:35 A.M. confirmed there was no physician's order for the Prevalon boots and they were not included on the plan of care. She stated the boots had been in place since 11/10/24. 4.Review of the medical record for Resident #81 revealed an admission date of 08/12/25 and diagnoses including anxiety disorder, fibromyalgia, and chronic pain syndrome. The resident had a physician's order for Tramadol 50 milligrams every six hours as needed for pain. Review of controlled substance administration records revealed the Tramadol was signed out as given

on 08/17/25 at 5:46 A.M., 08/25/25 at 5:00 A.M,, 08/26/25 at 6:19 A.M., 08/29/25 at 3:00 P.M., 08/30/25 at 9:40 P.M., and 09/06/25 at 1:29 P.M. Review of the medication administration records for August, and September 2025 revealed that those doses were not signed as given on the medication administration records. Interview with [NAME] President of Clinical Operations #300 on 09/23/25 at 9:00 A.M. confirmed

the documentation for the doses of Tramadol given to Resident #81 did not match on the medication administration records and the controlled substance administration records and should have.

Event ID:

Facility ID:

If continuation sheet

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

10/15/2025

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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

of the controlled substance administration records for Resident #81 revealed on 08/28/25, two sheets and two cards were delivered (one with 30 pills and one with 15 pills). Both sheets and both cards were placed into the narcotic counts. By only signing in one sheet and one card, you would be able to take out a card and sheet belonging to someone else without the count being off. Interview with Regional Nurse #200 on 09/17/25 at 10:30 A.M. and 10:50 A.M. revealed the initial allegation was made on 09/03/25. She confirmed there were Oxycodone sent for Resident #51 that are not accounted for from the documentation. She confirmed the facility did not have a summary or conclusion of their investigation into the allegation of missing narcotics for Resident #51. She stated that since the allegation focused on RN #227, she was drug tested. (Test negative on 09/06/25). She confirmed the facility did not investigate the allegation regarding

the Alprazolam being signed in inappropriately for Resident #81. She confirmed that RN #227 only signed

in one sheet and one card of Alprazolam for Resident #81 on 08/28/25. She confirmed it should have been two sheets and two cards. She confirmed that it was around that time when Resident #51's card of oxycodone was missing (08/29/25 per staff statements). She confirmed Resident #51 did not receive any Oxycodone from 08/28/25 to 08/31/25, when more were sent on 08/31/25. She stated that education was done with nursing on the day she was aware of the allegation (09/03/25) after it was determined what a mess it was. She stated that the pharmacy was notified 09/03/25 but was not involved in doing any investigation into missing narcotics. She stated she was notified last night that Resident #51 stated she did not receive a pain pill. She stated that the unit manager had called RN #227 to verify that she gave the medication. She stated she was not aware that Resident #51 had stated that RN #227 was stealing her medications. Interview with LPN/Unit Manager #175 on 09/17/25 at 1:30 P.M. confirmed Resident #81 had two count sheets for Alprazolam on 08/28/25 when RN #227 only signed one into the count. She stated this would make the count wrong unless a card and sheet were removed by someone. RN #227 was observed working in the facility on B-Hall on 09/16/25 and 09/17/25 on day shift. Interview with Administrator #188 and Regional Director of Operations #350 on 09/29/25 at 3:00 P.M. confirmed there were no attendance records for QAPI meetings. Administrator #188 confirmed there was no evidence of weekly meetings to discuss progress with a cot transportation contract. Administrator #188 confirmed the QAPI meeting 09/03/25 did not identify any issues with misappropriation of narcotics. There was no evidence the governing body was involved with any of the QAPI meetings. Interview with Regional Director of Operations #350 and Regional Director of Clinical Services #201 on 09/29/25 at 1:40 P.M. revealed they were not aware prior of any of the issues identified by survey team including failure to provide transportation and ordered medication for Resident #79 resulting in osteomyelitis of the foot, misappropriation of narcotics for Resident #51, failure to identify a significant change in condition for Resident #95 resulting in severe dehydration and death, and significant medication errors for Residents #3 and #40. Review of the policy dated July 2016 and titled Quality Assurance and Performance Improvement (QAPI) Committee revealed

the facility shall establish and maintain a QAPI Committee that oversees the implementation of the QAPI program. The committee shall be a standing committee of the facility and shall provide reports to the Administrator and governing body. Goals of the committee included establish, maintain, and oversee facility systems and processes to support the delivery of quality of care and services; Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately; Support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systemic problems; Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals. This deficiency represents incidental findings of noncompliance investigated under Complaint Number 2623671.

Event ID:

Facility ID:

If continuation sheet