Health inspection·January 26, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Self-Reported Incident (SRI) review, observation and interview, the facility failed to ensure exit doors were maintained in good repair to prevent elopement for Resident #50. This affected one (Resident #50) of two residents identified as elopement risk. Findings include: Review of the closed medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including type II diabetes, hyperlipidemia, depression, history of falling, dementia, psychotic disturbance, mood disturbance, osteoarthritis, prostatic hyperplasia, hypertension, unsteady on feet, generalized anxiety, and major depressive disorder. The resident was on a regular diet with thin liquids, received boost breeze, he utilized a walker, and an order for a posterior scalp abrasion to clean and leave open to air from a fall. He had orders for elopement bracelets to lock and alarm exit doors. The resident was discharged to a locked facility on 12/10/25.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 was moderately impaired for daily decision making.Review of Resident #50's progress notes included on 10/25/25 the resident went out the dining room doors after supper and staff got him in the facility. A 10/26/25 note included Resident #50 exited through the dining room doors twice and staff redirected him back into the facility.Review of a Risk Evaluation dated 12/10/25 revealed Resident #50 had a history of elopement or an attempted elopement while at home, verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door, and wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.). Review of a SRI tracking number 268449 dated 12/10/25 included the facility was alerted, by an anonymous neighbor, at 2:52 A.M. that Resident #50 had walked out of the facility. The resident was located at the entrance sign at the end of the driveway and easily redirected back to the facility. Once the resident was inside the facility, staff assisted him in getting into his pajamas and laid down in bed. Resident #50 was put on one-on-one supervision at 3:00 A.M. (and remained on one-on-one supervision until his discharge from the facility to a locked unit at 3:53 P.M. on 12-10-25. There was no evidence of a door locking and alarming, in response to a resident with an elopement alert bracelet near the exit door, to alert the staff the resident left the facility.Review of statements revealed Certified Nurse Aide (CNA) #135 observed Resident #50 sitting in front of the nurse station at 2:40 A.M. Licensed Practical Nurse (LPN) #164 reported she was notified at 2:50 A.M. that the resident was outside. He was located at the end of the driveway with his walker and brought back to the facility. The resident was dressed in shoes, pants, shirt and had a jacket on. The resident was given a head-to-toe assessment which did not provide any signs of injury. The resident had his elopement alert bracelets on at the time he left the facility. The SRI included the Wander-guard system, door alarm, evaluated by corporate maintenance, and it was found to be functioning correctly. The alarm company found that the door alarms were working inconsistently.Interview on 01/22/26 at 10:20 A.M. with Maintenance #158 revealed he found out about the 12/10/25 Page 1 of 2 365699 365699 01/26/2026 Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few elopement when he arrived around 7:00 A.M. He went around and checked the doors to see if the alarms were working. He found out the alarms on the long-term care unit were functioning. His weekly alarm checks have all the doors passing but he included sometimes they function properly right away, and other times it could take three or four tries to get the door to function correctly. He included he alerted the Administrator of the doors not always working as expected and was told to fix the doors. He would fix the doors to find out later the fix was inconsistent. He also included there were some issues he could not fix.Interview on 01/22/26 at 10:22 A.M. with the Director of Nursing (DON) revealed there was no record that staff checked the alert bracelets that were on the resident to see if the batteries were working at the time of the elopement. There was also no record of them checking the doors for functioning until morning. The DON included residents at risk for elopement wear two alert bracelets due to the facility having two different alarms on exit doors. The dining room door had a different alarm system than the front door.Observation 01/22/26 between 10:38 A.M. and 10:55 A.M. of the front door revealed when the bracelets that were to be worn by residents who were a risk for elopement were in the proximity of the door, they did not lock the door or alarm consistently. Testing revealed staff could walk out the door when holding the bracelets without the doors locking to prevent an elopement. When the staff service door was passed through the door did not alarm or lock because it was ajar. The dining room door that used a different alarm system alarmed when approached but did not lock and other times would not lock or alarm.Interviews on 01/22/25 at the time of the door observations with Maintenance #157, Regional Maintenance #168 and Director of Life Safety #167 verified the exit doors were not functioning to lock and alarm as they should to alert staff that a resident at risk of elopement, wearing an alert bracelet, was near or exiting the door.Interview on 01/22/26 at 12:29 P.M. with CNA #135 revealed the night of the elopement none of the doors alarmed to alert staff. She included they thought after they got him back into the facility that he went out the dining room door because she had not noticed the door to lock or alarm. The door was fairly easy to open. If he can open it, he will. The front door does not always close and so it will be ajar and not lock or alarm. When she sees the front door not fully closed, she closes the door.Interview on 01/22/26 at 3:08 P.M. with CNA #147 included the dining room door, to her knowledge, doesn't have an alarm and doesn't lock. The front door will stay ajar. Another lock was put on the front door, but it still stays ajar and opened at times. She included no door alarms went off the night Resident #50 left the building.Interview on 01/22/26 at 5:38 P.M. with the Administrator revealed there might have been a surge that affected the doors to start working on an off. The Administrator included if a resident pushes on the door to get out it can get out of alignment and not work as expected. The Administrator verified the exit door alert systems have been an issue. He verified the facility did not get a quote for an upgraded or new alarm system until 12/10/25, the day Resident #50 left the building during the night. This deficient practice represents non-compliance investigated under Master Incident Number 2694236. 365699 Page 2 of 2