Country Lane Gardens Rehab & Nursing Ctr

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

I was watching you. Regional DON verified the statements by Resident #3, Resident #49, and LPN #303 were discovered lying on the unit manager's desk and were not included in the information provided.

Regional DON verified the nursing note describing the incident as entered on 10/29/25 at 5:44 A.M., there was also an additional nursing statement on 10/29/25 at 5:38 P.M. about Resident #3 pushing a resident, a statement by CNA #115 revealed the incident occurred on 10/29/25 around supper time, and the SRI was reported to the state agency on 10/29/25 at 8:55 P.M. Regional DON was unable to verify if the incident on 10/29/25 at 5:44 A.M. was reported immediately.The Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy and procedure dated 11/01/19 revealed facility staff should immediately report all such allegations to the Administrator/designee and to the Ohio Department of Health in accordance with

the procedures in this policy. All incidents and allegations of abuse, neglect, exploitation, mistreatment of a resident must be reported immediately to the administrator or designee.

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

11/26/2025

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

ignoring her. LPN #119 went to get the cigarette box and heard CNA #114 tell Resident #20 that LPN #119 was ignoring her. Resident #20 stated, that (expletive) was definitely ignoring you. LPN #119 walked away to get Resident #60 a cup of juice. A typed statement dated 11/09/25 of an interview with Resident #20 by Social Worker (SW) #190 revealed a nurse ignored the CNA when they asked for the cigarette box. The LPN had a smirk on her face. A resident wanted juice and the nurse said they would get the juice. The nurse got the juice instead of the cigarette box. Resident #20 stated it was a bunch of drama. Resident #20 also stated there was no yelling or cursing but the nurse (LPN #119) was a smartass. A typed statement dated 11/09/25 of an interview with Resident #60 by SW #190 revealed a staff member did not want to give her juice. Resident #60 did not know the staff members' name and stated someone did give her juice. A typed statement (no date) by Regional Director of Operations (RDO) revealed SRI #267325 was opened and closed with the allegation being unsubstantiated. An interview with Resident #60 revealed there was no negative outcome, and interviews or assessments of like residents showed there were no negative outcomes. The SRI was opened up (initial was opened on 11/09/25). The description of the allegation was put in correctly. LPN #119 allegedly spoke in an aggressive manner regarding getting juice for Resident #60. LPN #119 was suspended pending investigation. SW #190 interviewed the resident, and the resident had no concerns with LPN #119 and no issue with juice. When SRI was being updated and closed, the wrong information was put in including the following. LPN #302 was entered as the perpetrator instead of LPN #119. The summary in the SRI was from another SRI that was copied and pasted in the wrong one.

Although the wrong employee was put into SRI #267325, the facility completed and investigated allegations

in appropriate manner. An interview on 11/26/25 at 11:35 A.M. RDO verified he put the incorrect perpetrator into SRI #267325, the SRI narrative did not accurately describe the allegation, and the actual alleged perpetrator was still employed at the facility. Interviews with SW #190 and Regional DON on 11/26/25 at 12:43 P.M. verified on 11/07/25 CNA #114 asked for the DON's phone number. SW #190 stated she talked to CNA #114 on 11/07/25 and 7:26 P.M. but was not aware of an allegation of abuse. The allegation of abuse was reported to the RDO on 11/09/25 at 2:37 P.M. The Regional DON verified the allegation of abuse was not immediately reported. The Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy and procedure dated 11/01/19 revealed facility staff should immediately report all such allegations to the Administrator/designee and to the Ohio Department of Health in accordance with the procedures in this policy. If a staff member is accused or suspected of abuse, neglect, exploitation, or mistreatment of a resident, the facility should immediately remove that staff member from the facility. All incidents and allegations of abuse, neglect, exploitation, mistreatment of a resident must be reported immediately to the administrator or designee. This deficiency is an example of continued non-compliance from the survey dated 10/15/25.

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

11/26/2025

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

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

was reported, and when RDO was made aware of the allegation of abuse. RDO was unable to provide information to coincide with Resident #3 touching Resident #49 in a nonaggressive manner.On 11/26/25 at 1:46 P.M. Regional Director of Nursing (DON) provided two handwritten statements completed by herself dated 10/30/25 that Resident #3 and Resident #49 could not recall the events. Regional DON also provided

a handwritten statement dated 10/29/25 by LPN #303 (no longer employed at the facility). The statement revealed Resident #49 was standing by the elevator and Resident #3 was sitting in a chair near the elevator. Resident #3 began yelling at Resident #49 and told Resident #49 to move away from him. The nurse stood up, and Resident #3 also stood up yelling and pushed Resident #49. The nurse separated the residents and told Resident #3 to go to his room and calm down. Resident #3 argued for a few minutes and then went to his room. Resident #3 returned to the nurse and showed the nurse his hand and stated Resident #49 had hit him. The nurse told Resident #3 no he didn't hit you-you hit him. I was watching you.

Regional DON verified the statements by Resident #3, Resident #49, and LPN #303 were discovered lying

on the unit manager's desk and were not included in the information provided. Regional DON verified the nursing note describing the incident as entered on 10/29/25 at 5:44 A.M., there was also an additional nursing statement on 10/29/25 at 5:38 P.M. about Resident #3 pushing a resident, a statement by CNA #115 revealed the incident occurred on 10/29/25 around supper time, and the SRI was reported to the state agency on 10/29/25 at 8:55 P.M. Regional DON was unable to verify if the incident on 10/29/25 at 5:44 A.M. was reported immediately.The Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy and procedure dated 11/01/19 revealed facility staff should immediately report all such allegations to

the Administrator/designee and to the Ohio Department of Health in accordance with the procedures in this policy. All incidents and allegations of abuse, neglect, exploitation, mistreatment of a resident must be reported immediately to the administrator or designee. This deficiency is an example of continued non-compliance from the survey dated 10/15/25.

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

11/26/2025

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)

Federal health inspectors cited COUNTRY LANE GARDENS REHAB & NURSING CTR in PLEASANTVILLE, OH for a deficiency under regulatory tag F-F0628 during a complaint investigation conducted on 2025-11-26.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 4 deficiencies cited during this inspection of COUNTRY LANE GARDENS REHAB & NURSING CTR.

Correction Status: Deficient, Provider has no plan of correction.