Health inspection·June 10, 2025

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** THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the facility Self-Reported Incident (SRI), staff interview, family interview and policy review, the facility failed to maintain a safe environment and provided adequate supervision to prevent Resident #10, who was cognitively impaired, from eloping from the facility without staff knowledge. This affected one (Resident #10) of three residents reviewed who were identified by the facility as having exit seeking and/or wandering behavior. The facility census was 65. Findings include: Review of the medical record for Resident #10 revealed an admission date of 12/23/24. Diagnoses included Wernicke's encephalopathy, with chronic alcohol use disorder, seizure disorder, history of urinary tract infection and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was mildly cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Resident #10 was independent with activities of daily living and required cueing and assistance at times. Review of the care plan dated 04/21/25 revealed Resident #10 was at risk for elopement. He walked throughout the facility independently with a Wanderguard (a safety bracelet to prevent residents from wandering into unsafe areas or leaving the facility unsupervised) on his right ankle. Review of the nurse's progress notes from 05/23/25 to 05/25/25 revealed Resident #10 somehow removed his Wanderguard on 05/23/25. Staff completed a search of Resident #10's room and belongings. Interviews conducted with other residents revealed no indication of how Resident #10 removed his alarm. Review of Resident #10's nurse's progress note dated 05/25/25 revealed Licensed Practical Nurse (LPN) #215 went to check on Resident #10 around 7:45 P.M. and noted he was missing. All staff were notified, and an elopement drill was announced, a search began, the Director of Nursing (DON) was notified immediately and arrived at the facility within ten minutes, 911 was called, police arrived and took report, and a community search began. Meanwhile the entire property was being searched in and out. The Assistant Director of Nursing (ADON) was in her car traveling around the area looking for the resident. At approximately 8:50 P.M., Resident #10's guardian was notified and reported Resident #10, her son, was sitting at her dining room table eating dinner. Resident #10's guardian did not call the facility to notify the staff when he arrived. Police were notified, and Resident #10 returned to Page 1 of 4 365815 365815 06/10/2025 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility at 10:45 P.M. escorted by the police. A new Wanderguard was placed on the resident's right ankle, and he has had a one-on-one sitter since his return. It was unknown how he removed the monitor on 05/25/25. Review of Resident #10 Elopement Evaluation completed on 12/23/24 revealed he was at no risk for elopement. On 01/06/25 a score of seven indicated Resident #10 was at a high risk for elopement. Elopement Evaluations completed on, 01/06/25, 05/26/25 and 05/30/25 scores of six and five indicating Resident #10 continued to be a risk for elopement Review of SRI tracking number 260836 revealed on 05/25/25 approximately 8:00 P.M. Resident #10 was unable to be located within the facility. Elopement procedures were activated and a complete search in the facility and outside the facility began. 911 was called and the local police arrived at the facility. A missing person was activated in the community. Administration arrived, and the DON called the residents guardian/mother who reported he was at her house approximately two miles from the facility. The police escorted Resident #10 back to the facility without incident. The following was completed upon residents return to the facility: • Head-to-toe skin assessment and resident interview was initiated on Resident #10. • Resident's psychosocial needs were assessed by staff and counseling services were ordered. • The resident was placed on a one-on-one intervention and, a new Wanderguard was placed on his right ankle. • Facility staff searched Resident #10's room and all common areas for sharp objects resident could have used to remove the Wanderguard. Interview on 06/09/25 from 3:30 P.M. to 4:00 P.M. with Resident #10 and his family revealed Resident #10 was alert and oriented to person, place and time. He admitted he did leave the facility recently after taking his Wanderguard off. He refused to disclose how he was able to remove the Wanderguard. He explained I walked down the long drive, crossed the road walked down the sidewalk to a park, sat on the bench for a while, enjoyed the fresh air and walked across the high school's football field to his mother's house which was approximately two miles away, and I had dinner with my mother. I was returned to the facility by the police. During the interview, Resident #10's legal guardian/mother was not worried that her son left the facility, he called her every night and told her he doesn't like being in the facility. She believes Resident #10 needs more to do at the facility to keep him busy. Review of the undated facility policy titled Elopement Program Policy, revealed the facility will maintain an elopement program designed to prevent and manage incidents of elopement. 365815 Page 2 of 4 365815 06/10/2025 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The deficient practice was corrected on 05/26/25 when the facility implemented the following corrective actions: • When Resident #10 returned to the facility on [DATE] a head-to toe skin assessment and resident interview was initiated. • On 05/25/25 Resident #10 was placed on one-on-one intervention and a new Wanderguard was placed on the resident. • On 05/26/25 Resident #10 psychological needs were assessed by staff, and he was added to counseling services. • On 05/26/25 all like residents' care plans and orders were reviewed for those at risk for elopement and visualization placed on actual Wanderguards on their person completed • On 05/26/25 elopement risk assessments were completed for all current facility residents. • On 05/26/25 the previous 30 days of nurse's progress notes reviewed for all current facility residents to assess documentation of residents verbalized or attempted to leave. The intervention will be in real time, five times per week for four weeks. • On 05/25/25 Wanderguard system and all facility doors checked to ensure working within normal limits and then starting 05/26/25, the exit doors will be audited five times a week for one week, then weekly times three weeks to ensure the Wanderguard system and exit doors continue to work properly. • On 05/25/25 all residents with Wanderguards will be checked for proper placement and functionality. Audit will occur five times per week for four weeks. • On 05/25/25 night staff were educated on elopement policy when Resident #10 returned to the facility. 365815 Page 3 of 4 365815 06/10/2025 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0689 • Level of Harm - Minimal harm or potential for actual harm On 05/26/25 an elopement drill was completed, and additional elopement drills will be completed every shift for seven days, then two to three times per week, then weekly times two weeks. Residents Affected - Few • On 05/26/25 and 05/27/25 all other staff were educated on the elopement policy and procedures. • On 5/26/25 all staff were educated to not leave objects in common areas one could use to remove a Wanderguard initiated and completed. Common areas will be monitored five times a week times two weeks, then two times a week, then weekly times four weeks to ensure there are not any objects that residents could use to remove a Wanderguard. • On 5/26/25 staff educated on the expectations of 15-minute checks on residents and policy and procedures of utilizing a one-on-one sitter. The DON or designee will audit the one-on-one sheet for Resident #10 five times a week for four weeks to ensure there are no gaps in coverage. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00166053. 365815 Page 4 of 4