Country Lane Gardens Rehab & Nursing Ctr

hospital.Interview with Acting Director of Nursing #303 on 09/24/25 at 2:00 P.M. confirmed there was

hospital on [DATE].This deficiency represents noncompliance investigated under Complaint Numbers

366199 10/15/2025

Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

Review of the facility policy last revised [TRUNCATED]

366199 10/15/2025

Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

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.

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Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

symptoms present a danger to the resident and others and the symptoms are identified as being due

Interview with the Acting Director of Nursing #303 on 09/24/25 at 2:00 P.M. confirmed there was no

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.

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Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

Review of the controlled substance administration records for Resident

sheet and one card, you would be able to take out a card and sheet belonging to someone else without

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, 2608729.

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Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

in gaps in protection for other residents on the locked unit.

Complaint Numbers 2615387, 2608772, 2608729.

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Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

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 2596564.

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Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

Review of the policy titled Change in a Resident's Condition or Status revealed the

jeopardy to resident health or representative of changes in the resident's medical/mental condition.

Further review revealed nurse safety 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] revealed that under the area of services and

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

• 366199 10/15/2025

Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

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.

366199 10/15/2025

Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

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.

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Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

noncompliance investigated under Complaint Number 2623671.

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Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

nurses on a full time basis.

the facility failed to provide eight hours of consecutive Registered Nurse (RN) direct care and had the

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.

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Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

services.

review of the medical record and staff interviews, the facility failed to implement appropriate

three residents reviewed for behavioral services.

The facility census was 94.Findings include:Review of the medical record for Resident #14 revealed an admission date of 02/17/25 with diagnoses that included Anoxic brain damage, dementia, bipolar disorder, major depressive disorder, hepatitis C, edema, post-traumatic stress disorder (PTSD), attention deficit disorder, opioid use, anxiety disorder, iron deficiency anemia, vitamin deficiency, female pelvic inflammatory disease, psychoactive substance abuse, insomnia, dementia, and nightmare disorder.

Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #14 required setup for eating and oral hygiene, supervision for most daily activities and transfers, maximal help for showering, and could walk up to 150 feet with supervision.

Review of the care plan, initiated 02/18/25 and revised through 09/15/25, documented a history of sexually inappropriate behaviors.

Interventions included administering medications, involving behavioral health as needed, monitoring for wandering, providing safe-practice education, and immediate removal from situations where inappropriate behavior occurred using one-to-one (1:1) supervision when necessary.Interview on 09/24/25 at 8:32 A.M. with Licensed Practical Nurse (LPN) #248 revealed that she was informed Resident #14 engaged in sexual behaviors with a male resident (#50). LPN #248 stated that she believed Resident #14 required a female-only facility due to her age and history of anoxic brain injury, and expressed concern that placement on the dementia floor increased risk to other residents.

She confirmed that she was unsure who had observed the incident and that Resident #14's behavior was ongoing.Interview on 09/24/25 at 8:41 A.M. with Certified Nursing Assistant (CNA) #163 revealed that she was not present during the incident between Resident #14 and Resident #50 but confirmed that the situation was reported to nursing staff and witness statements were completed.

She confirmed that following the incident, Resident #14 was placed on 1:1 supervision.Interview on 09/24/25 at 9:00 A.M. with CNA #167 confirmed that Resident #14 was observed inappropriately touching Resident #50 and stated that she was not aware of any preventive measures in place prior to the incident.

She reported that Resident #14 was on 1:1 supervision for a few hours and then placed on 15-minute checks.Interview on 09/24/25 at 9:36 A.M. with Resident #14's guardian, confirmed that the facility moved Resident #14 to a new unit following the incident.

She stated that she believed Resident #14 would engage in sexual activity if she wanted and recommended placement in an all-female facility.Interview on 09/24/25 at 9:59 A.M. with LPN #189 confirmed that the incident between Resident #14 and Resident #50 occurred on 09/19/25 between 10:00 and 11:00 A.M.

She reported that Resident #14 was removed from the room and placed on 1:1 supervision, but no additional interventions were completed prior to her move to another unit.Interview on 09/24/25 at 10:36 A.M. with Regional Director (RD) #350 confirmed that staff moved Resident #14 to the locked unit due to her sexual behaviors. He reported that no alternative interventions or individualized behavioral strategies were documented prior to placement on the locked unit.Interview on 09/24/25 at 11:38 A.M. with Social Services Director (SSD) and HR Director #152 confirmed that psychosocial assessments for both residents were completed verbally but not documented, and that a late progress note would be submitted using witness statements as reference.Interview on 09/25/25 at 9:46 A.M. with RD #350 and Administrator confirmed plans to place Resident #14 in a more appropriate facility and maintain 1:1 supervision until an appropriate placement was located.This deficiency represents incidental finding of non-compliance investigated under Master Complaint Number 2623748.

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Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

Review of the controlled

P.M. was not documented as given.

Review of the medication administration record and the controlled

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.

366199 10/15/2025

Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

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 further stated that once the administrator and State survey agency are notified, an investigation of the allegation violation will be conducted.

The investigation must be completed within five working days, unless there are special circumstances.

Evidence of the investigation should be documented.

After completion of the investigation, all of the evidence should be analyzed and the administrator will make a determination regarding whether the allegation or suspicion is substantiated.

Review of the Facility Assessment Tool dated 09/29/25 revealed it listed facility resources needed to provide competent support and care for our resident population every day and during emergencies. It included Administration and stated that the facility employs a number of administrative, non-direct care personnel to meet the needs of our residents. A full-time Nursing Home Administrator is on duty as well as a Business Office Manager. A social services/human resources worker and social services assistant addresses the social needs of our residents while an Activities Director and Activity Assistants offer an extensive array of in-house and outside activities.

Review of a Job Description and Performance Standards for the Administrator revealed the purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet resident needs in compliance with federal, state, and local requirements.

Authority is delegated to the individual in this position to: develop, maintain, and implement operational policies and procedures to meet resident needs in compliance with federal, state, and local requirements; determine the personnel requirements of the facility and hire or arrange for sufficient staff to implement the facility policies and procedures; develop a monitoring system to assure compliance with federal, state, and local requirements. It further stated the primary functions and responsibilities of this position included: act as a liaison to the governing body for the medical, nursing, and other professional staff and all facility departments.

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

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Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

appropriately; Support the use of root cause analysis to help identify where patterns of negative

deficiency represents incidental findings of noncompliance investigated under Complaint Number

366199 10/15/2025

Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

Review of the medication administration record revealed Ferrous

weeks. (Epoetin alfa is used to treat anemia by stimulating the production of red blood cells.

Review

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.

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Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

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.

366199 10/15/2025

Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

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.