Country Lane Gardens Rehab & Nursing CTR

In the surveyor’s words

From the most serious findings on record at Country Lane Gardens Rehab & Nursing CTR, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Aug 24, 2026

  Based on observation, record review, interview with staff and representatives from the local health department (LHD), and review of the facility water management plan, the facility failed to develop and implement an effective water management program to monitor control measures and to prevent the growth of Legionella in the water system. This resulted in Immediate Jeopardy and Actual Harm beginning on 07/27/26 when Resident #9, who demonstrated respiratory complications (i.e. shortness of breath and decreased oxygen saturation) tested positive for Legionella during a hospitalization. […]

• Immediate jeopardy, isolatedF744Feb 2, 2026

  Based on review of medical records, interviews with staff and the contracted psychiatric mental health nurse practitioner, review of facility self-reported incidents (SRIs), review of facility investigation documents, and review of facility policies and clinical protocols, the facility failed to ensure residents with a diagnosis of dementia and history of sexually inappropriate behaviors received adequate and effective behavioral health services to address their need for individualized interventions, monitoring, and supervision. […]

• Immediate jeopardy, isolatedF600Oct 15, 2025

  Based on observation, record review, review of a facility timeline of events, review of hospital records and a physician after visit summary, facility policy review and interview, the facility failed to prevent an incident of neglect involving Resident #32. This resulted in Immediate Jeopardy and Actual Harm beginning on 09/19/25 at 10:30 A.M. when Resident #32, who was identified to have confusion and poor decision making, was left outside the facility in the sun with the air temperature between 82 and 85 degrees Fahrenheit unattended. On 09/19/25 at approximately 1:45 P.M. Resident #32 was found outside the facility unresponsive with a body temperature of 107 degrees (F) and an oxygen saturation level of 88 percent with resulting second degree burns/blisters on her arms and legs. […]

• Immediate jeopardy, isolatedF684Oct 15, 2025

  Based on closed medical record review, hospital record review, death certificate review, facility policy and procedure review, facility assessment review, and interview, the facility failed to timely identify and provide comprehensive, resident centered interventions following an acute change in condition for Resident #95. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on 06/27/25 when Resident #95, who had severe cognitive impairment and required staff assistance with activities of daily living (ADL) was noted by staff to have an acute change in medical condition which included dusky colored hands and feet, limited food and fluid intake, lethargy, and the need for supplemental oxygen. […]

• Immediate jeopardy, isolatedF692Jul 8, 2024

  Based on observation, medical record review, facility policy and procedure reviews and interviews, the facility failed to ensure Resident #9, who was identified as nutritional risk, was provided a comprehensive and individualized nutritional plan to include monitoring of nutritional status, physician notification of diet changes and discharge from hospice services, and implementation of nutritional interventions to prevent weight loss and honor the resident's right for food preferences. […]