Health inspection·August 15, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, policy review, and interview, the facility failed to notify physician and family of abnormal radiology results. This affected one resident (#14) of three residents reviewed for notification. The facility census was 89.Findings Include:Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, heart failure, and other toxic encephalopathy.Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #14's cognition remained intact, and she had no behaviors.Review of nursing notes from 07/25/25 through 07/27/25 revealed no documented evidence of Resident #14 having a fall or being lowered to the ground.Review of a staff statement dated 07/27/25 by certified nurse aide (CNA) #140 revealed after Resident #14 finished using the bathroom, she stood up but was having trouble standing from the low toilet. CNA #140 helped Resident #14 up and the resident was standing very well while her pants were pulled up. After pants were up, Resident #14 became unstable and CNA #140 instructed her to sit back on the toilet but the resident began to fall. CNA #140 guided Resident #14 to the floor. CNA #140 pulled the call light and CNA #133 came in. CNA #133 stated the resident needed to get up, so CNA #140 and #133 got Resident #14 up and the resident did really well walking to bed. Resident #14 denied pain while walking but once in bed stated she may have hurt her foot. CNA #140 let the nurse know and asked when vitals should be taken. CNA #140 stated the nurse did not seem to care and went on a break.Review of a nursing note dated 07/28/25 at 7:08 P.M. by licensed practical nurse (LPN) #103 revealed Resident #14's physician gave new orders for a left ankle x-ray related to pain, a mobile x-ray company was called, and all parties were aware.Review of a nursing note dated 07/29/25 at 3:46 P.M. by LPN #105 revealed the note was a late entry for 07/26/25 at 6:20 P.M. LPN #105 was informed by Resident #14's spouse he took her to the bathroom and Resident #14 became dizzy so he put the wheelchair under her. Resident #14 was denying pain.Review of an order dated 07/29/25 revealed Resident #14 needed an orthopedic appointment due to left ankle fracture. An additional order dated 07/29/25 revealed Resident #14's left ankle/foot was to be wrapped with ace wrap and she was non-weight bearing for left ankle fracture.Review of an x-ray dated 07/29/25 revealed Resident #14 had an acute, minimally displaced fracture at the distal fibula with adjacent soft tissue swelling.Interview on 08/13/25 at 11:10 A.M. with Resident #14 and the resident's spouse revealed the resident was not made aware of the abnormal x-ray results until an aide let it slip to her. Resident #14's spouse could not recall if he was notified.Interview on 08/13/25 at 2:03 P.M. with the Administrator confirmed there was no evidence Resident #14, or her family were notified of the abnormal X-ray results. The Administrator verified there was no documented evidence Resident #14's physician was notified of the resident's fall on 07/26/25 with subsequent complaints of pain.Review of a policy titled Change in Condition (undated) revealed the nurse will notify physician when there has been an accident or incident involving the resident, discovery of injuries of Page 1 of 5 366199 366199 08/15/2025 Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

F 0580 Level of Harm - Minimal harm or potential for actual harm an unknown source, or other change in condition. Prior to notifying the physician, the nurse will make detailed observations and gather relevant information and pertinent information for the provider. Unless otherwise instructed by the residents, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental or psychosocial status.This deficiency represents non-compliance investigated under Complaint Number 2583218. Residents Affected - Few 366199 Page 2 of 5 366199 08/15/2025 Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, policy review and interview, the facility failed to provide timely diagnostic services and treatment when Resident #14 complained of pain to her ankle after a fall. This affected one resident (#14) of three residents reviewed for change in condition. The facility census was 89. Findings include:Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, heart failure, and other toxic encephalopathy. The resident was discharged from the facility on 08/01/25. Review of a care plan dated 07/14/25 revealed Resident #14 was at risk for falls, goals included to be free of minor injuries and major injuries during her stay. Interventions included but were not limited to anticipate and meet resident's needs, call light in reach, education on safety reminders and what to do if a fall occurs, ensure proper footwear, and therapy as needed.Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14's cognition remained intact, and she had no behaviors.Review of nursing notes from 07/25/25 through 07/27/25 revealed no documented evidence Resident #14 had a fall or was lowered to the ground during this time period.Review of a skilled nursing note dated 07/25/25 at 12:26 A.M. by Licensed Practical Nurse (LPN) #101 revealed Resident #14's pain level was 0 (1-10 pain scale).Review of a skilled nursing note dated 07/25/25 at 11:16 P.M. by LPN #107 revealed Resident #14 had a pain level of 0 (1-10 pain scale).Review of the medication administration record (MAR) for 07/2025 revealed Resident #14 had a physician order for tramadol (narcotic pain medication) oral tablet 50 milligrams (mg) give 50 mg by mouth every eight hours as needed for pain starting on 07/21/25. Resident #14 received this medication on 07/27/25 at 6:35 A.M. for a pain level of five (5) (on a 1-10 pain scale with 10 being the most severe pain) and again on 07/27/25 at 5:30 P.M. for a pain level of six (6) (1-10 pain scale).However, there was no evidence comprehensive assessments of the resident's pain to include location, quality, intensity, onset, duration, aggravating/alleviating factor were completed on 07/27/25 related to the use of the as needed narcotic pain medication. Review of a skilled nursing note dated 07/27/25 at 11:05 P.M. by LPN #107 revealed Resident #14 had a pain level of two (2) (1-10 pain scale).Review of a staff statement dated 07/27/25 by (CNA) #140 revealed after Resident #14 finished using the bathroom on 07/26/25, she stood up but was having trouble standing from the low toilet. CNA #140 helped Resident #14 up and the resident was standing very well while her pants were pulled up. After her pants were up, Resident #14 became unstable, and CNA #140 instructed the resident to sit back on the toilet but the resident began to fall. The statement included CNA #140 guided Resident #14 to the floor, CNA #140 pulled the call light and CNA #133 came in. CNA #133 stated the resident needed to get up, so CNA #140 and #133 got Resident #14 up and (per the statement) the resident did really well walking to bed. Resident #14 denied pain while walking but once in bed stated she may have hurt her foot. The statement included the CNA #140 let the nurse know and asked the nurse when vitals should be taken. CNA #140 stated the nurse did not seem to care and went on a break. (The statement did not specify which nurse the incident was reported to.) Review of Resident #14's medical record revealed no written documentation/evidence the resident was lowered to the floor during a transfer on 07/26/25. Review of a nursing note dated 07/28/25 at 7:08 P.M. by LPN #103 revealed Resident #14's physician gave new orders for a left ankle x-ray related to pain, a mobile x-ray company was called, and all parties were aware. Review of the MAR for 07/2025 revealed Resident #14 received tramadol oral tablet 50 milligrams (mg) on 07/29/25 at 12:48 A.M. for a pain level of four (4) (1-10 pain scale). Review of the MAR for 07/2025 revealed Resident #14 received tramadol oral tablet 50 milligrams (mg) on 07/29/25 at 11:34 P.M. for a pain level of three (3) (1-10 pain scale).However, Residents Affected - Few 366199 Page 3 of 5 366199 08/15/2025 Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there was no evidence comprehensive assessments of the resident's pain to include location, quality, intensity, onset, duration, aggravating/alleviating factor were completed on 07/29/25 related to the use of the as needed narcotic pain medication. Review of a nursing note dated 07/29/25 at 3:46 P.M. by LPN #105 revealed the note was a late entry for 07/26/25 at 6:20 P.M. when LPN #105 was informed by Resident #14's spouse he took her to the bathroom and Resident #14 became dizzy so he put the wheelchair under her. The late entry note revealed Resident #14 denied pain. Review of an x-ray report dated 07/29/25 revealed Resident #14 had an acute, minimally displaced fracture at the distal fibula with adjacent soft tissue swelling. Review of an order dated 07/29/25 revealed Resident #14 needed an orthopedic appointment due to left ankle fracture. An additional order dated 07/29/25 revealed Resident #14's left ankle/foot was to be wrapped with an ace wrap and she was non-weight bearing for left ankle fracture. There was nothing documented in the resident's medical record and nurse's notes related to this order. Review of a skilled nursing note dated 07/30/25 at 6:58 A.M. by Registered Nurse (RN) #113 revealed Resident #14 had a pain level of seven (7) (1-10 scale) in her right arm and left foot. Review of a nursing note dated 07/30/25 at 6:00 P.M. by LPN #118 revealed Resident #14 returned from an orthopedic appointment with an air cast to her left foot. Review of a statement dated 07/30/25 by LPN #118 revealed Resident #14 stated her husband had her get up out of bed to go to the bathroom, got to the doorway of the bathroom, they did not bring the wheelchair with them so her husband left her standing to go get the wheelchair but he did not make it back fast enough so Resident #14 fell back before he reached her, twisted left and fell to the floor. Resident #14 stated she fell two more times throughout the night trying to stand up from her commode and the aides helped her back up and into bed. The statement did not specify the date the incident occurred. Review of an orthopedic consult note dated 07/30/25 revealed Resident #14 had a fall on 07/27/25 (the resident's nursing home record indicated the resident had fallen on 07/26/25) and had immediate left ankle pain. Resident #14 had mild swelling, and tenderness to palpation along the lateral aspect of the ankle at the lateral malleolus. An x-ray completed in office revealed a nondisplaced [NAME] B ankle fracture and (the resident) should be weightbearing as tolerated in a high tide walking boot with a follow up in two weeks to evaluate if weightbearing caused any displacement.Review of an order dated 07/31/25 revealed Resident #14 was to wear an air cast to her left foot. Interview on 08/13/25 at 10:25 A.M. with LPN #105 revealed Resident #14 had an ankle fracture and a couple stories had been told. LPN #105 stated Resident #14's spouse stated he was walking her to the bathroom and pulling the wheelchair when she got dizzy and light-headed so she sat down. Then, Resident #14's spouse told her Resident #14 fell in the bathroom and got her foot stuck between the toilet and the wall. LPN #105 stated she did not hear about ankle pain until her next shift. LPN #105 stated when she went to speak to Resident #14, she was eating and said she was fine and had no pain. LPN #105 stated she educated Resident #14's spouse not to transfer resident without assistance and he responded he would do what he wanted. LPN #105 could not recall specific dates.Interview on 08/13/25 at 11:10 A.M. with Resident #14 and her spouse revealed she had fallen and broken her ankle while she had resided in the facility. Resident #14 revealed staff knew she had fallen and did not need to notify her spouse since he was present. Resident #14 stated they took a while to get an x-ray and no one notified her of the results, but the aide accidentally told her. Her spouse could not recall if he was notified.Interview on 08/13/25 at 1:12 P.M. with CNA #122 revealed Resident #14 told her about a fall she had and her ankle was hurting. CNA #122 stated Resident #14 thought her ankle was sprained. CNA #122 stated she reported to the nurse but could not recall which nurse. CNA #122 stated the nurse had told her since it happened on nightshift, nightshift needed to be the one to enter the fall assessment. CNA #122 366199 Page 4 of 5 366199 08/15/2025 Country Lane Gardens Rehab & Nursing Ctr 7820 Pleasantville Road Pleasantville, OH 43148

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident #14 was not crying but stated it did hurt pretty bad. CNA #122 could not recall the exact date the resident had told her about this.Interview on 08/13/25 at 1:15 P.M. with CNA #125 revealed Resident #14 informed her she had a fall and it was also passed along in report. Resident #14 stated she had fallen and hurt her foot but did not mention how. CNA #125 stated Resident #14 did not specify how much pain she had, just that it hurt. CNA #125 stated she reported the resident complaints to the nurse (unable to recall which nurse), and the nurse stated she would let the doctor know. CNA #125 could not recall which day this occurred.Interview on 08/13/25 at 1:19 P.M. with CNA #130 revealed Resident #14 stated her left ankle was hurting her and she had reported she had a fall on 07/26/25. Resident #14 did not provide details of the fall. CNA #130 stated Resident #14 told her she had multiple falls, and her foot and ankle were hurting. CNA #130 stated Resident #14 appeared to be in pain because every time staff touched her leg or went to move her, she would grimace. Resident #14 reported it was a sharp pain, like she sprained the ankle. CNA #130 stated she reported to LPN #107 who stated she was aware, and the dayshift nurse would have to take care of it.Multiple attempts were made to contact LPN #107 and were unsuccessful.Interview on 08/13/25 at 1:27 P.M. with CNA #133 revealed he recalled Resident #14 had been lowered to the floor by her spouse around 6:30-7:00 P.M. on either Friday (07/25/25) or Saturday (07/26/25) and he let the nurse know. CNA #133 stated he assisted in getting Resident #14 up prior to the nurse coming since her husband had already started to pick her up. CNA #133 stated Resident #14 did not complain of pain until later in the night. Resident #14 had a scrape to one of her legs below the knee from her wheelchair and complained of pain in the ankle. CNA #133 stated he told LPN #105 about the incident who went to Resident #14's room immediately.Interview on 08/13/25 at 2:03 P.M. with the Administrator confirmed there were no nursing notes (from 07/25/27- 07/27/25) related to falls or pain for Resident #14 until the x-ray was ordered (07/28/25). The x-ray note only indicated it was due to pain and no information about why the new onset of pain was occurring. The Administrator confirmed a late-entry note dated 07/29/25 for the date of 07/26/25 entered by LPN #105 revealed Resident #14 had a fall 07/26/25, after the note regarding the x-ray was entered. The Administrator confirmed the x-ray results were not in the nursing notes.Interview on 08/14/25 at 6:32 A.M. with CNA #140 revealed she was aware of several falls occurring for Resident #14. CNA #140 stated upon the beginning of their shift Saturday night (07/26/25) CNA #133 told her Resident #14 had a fall with her husband. CNA #140 stated when she saw Resident #14, she had complained of pain in her left foot. CNA #140 stated Resident #14 had another fall around 3:00 A.M. and when asked for assistance, CNA #133 came in to help her and they just lifted Resident #14 off the ground prior to any vitals or assessment being completed. CNA #140 stated this was confusing to her because other facilities she worked at followed protocol, like waiting for the nurse to assess the resident and take vitals. CNA #140 stated there was also a third fall later in the morning. CNA #140 stated Resident #14 was complaining of pain throughout the night. CNA #140 stated she wrote a statement and took a picture of it because she was told they (staff statements) usually go missing. CNA #140 stated her statement did not have many details because she was afraid of retaliation and her coworkers treating her poorly.Review of a policy titled Change in Condition dated 12/2016 revealed the nurse would notify the physician when there has been an accident or incident involving the resident, discovery of injuries of an unknown source, or other change in condition. Prior to notifying the physician, the nurse would make detailed observations and gather relevant information and pertinent information for the provider.This deficiency represents non-compliance investigated under Complaint Number 2583218 366199 Page 5 of 5