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 (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 4 Event ID: 365815 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 365815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050 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)