Heather Knoll Retirement Village

to wait on his sister for lunch. LPN #207 stated she observed Resident #61 being wheeled back to the unit by COTA #205 stating he was found outside. LPN #207 could not verify the door Resident #61 used or how long he was outside. LPN #207 stated she spoke to Resident #61 briefly explaining that he needed to sign out next time and make sure he was wearing appropriate clothing for the weather. LPN #207 stated Resident #61 stated he did not realize it was that cold outside. LPN #207 stated no assessments were completed or documented, that she called the DON who said Resident #61 had a BIMS of 15 so nothing else needed to be done. LPN #207 stated the doors that she assumed Resident #61 exited through automatically lock so Resident #61 would not be able to return inside.Interview on 01/29/26 at 12:59 P.M., Nurse Practitioner #208 stated someone called her to tell her Resident #61 was observed outside the facility, but Resident #61 was dressed appropriately and no significant changes were noted. NP #208 stated she spoke with Resident #61 on 01/22/26 but did not ask about the incident on 01/18/26.Interview on 01/29/26 at 1:10 P.M., the family of Resident #61 stated she received a call a couple weeks ago from staff stating they caught Resident #61 trying to leave the facility.

The family stated she received calls in the past stating Resident #61 was looking for the door but never left the facility.

The family stated Resident #61 had short-term memory dementia with sundowning episodes.

The family was not aware Resident #61 was observed outside without the facility without staff and not wearing a coat.This deficiency represents non-compliance investigated under Complaint Number 2723679.

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