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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365699 Printed: 05/15/2026 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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)