St. Leonard HCC: Resident Wanders to Yard Unsupervised - OH
The incident involved Resident #205, a person identified in facility records as someone at risk for wandering. The administrator confirmed the resident was found outside and assessed afterward. No physical injury was documented.
But the inspection, completed September 17, 2025, following a formal complaint, exposed something that went beyond one resident's close call.
The facility's current security system, called x-mark, has a feature that allows staff or visitors to press a button at the receptionist desk and silence the door alarm entirely. The Director of Nursing confirmed this during an interview that morning. That means at the moment Resident #205 walked out, the alarm either wasn't triggered or was suppressed. The report does not specify which. What it does specify is that the system allowed it to happen.
The Director of Nursing told inspectors the facility is in the middle of switching to a new system called Secure Care. New wiring is currently being installed. Once complete, she said, a wanderguard worn by a resident would trigger an alarm at any doorway, without exception, and no button press would silence it.
The upgrade isn't finished yet.
That gap, between the system the facility has and the system it's working toward, is where Resident #205 ended up outside.
The facility's own elopement and wandering policy, last updated May 22, 2025, states that residents who exhibit wandering behavior or are at risk for elopement receive adequate supervision to prevent accidents, and that care follows a person-centered plan addressing the specific factors that make that resident vulnerable. Inspectors cited the facility for failing to meet that standard.
The deficiency was tagged under F0689, which covers the obligation to protect residents from accidents the facility could reasonably anticipate. The level of harm was recorded as minimal harm or potential for actual harm. A few residents were identified as affected.
What the report leaves unresolved is how long the current system's vulnerability has been known internally, and how many residents wearing wanderguards have passed through alarmed doors during periods when the receptionist desk button was pressed. The inspection narrative does not say. It records what was confirmed, and what was confirmed is that the system can be silenced, that it was silenced or failed, and that a resident who needed protection from exactly this kind of accident was found outside.
The Secure Care installation is underway. Resident #205 was not injured.
Those two facts sit next to each other in the record without explaining the distance between them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Leonard Hcc from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 18, 2026 · Our methodology
ST LEONARD HCC in CENTERVILLE, OH was cited for violations during a health inspection on September 17, 2025.
The incident involved Resident #205, a person identified in facility records as someone at risk for wandering.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.